Chapter 1: Give every child the best start in life

Gender inequality begins before a baby is born, creating a lifelong cycle of inequality through behaviours, attitudes and actions that society feels are appropriate, or inappropriate, for a woman or man, girl or boy. Gender inequality is often rooted in cultural norms and traditions. These social norms are neither static nor universal and in fact, change over time.

Some social norms are positive, such as children should not smoke and babies and children should always be in a car seat when being driven. However, there are other social norms that lead to inequality. 

For example, girls are more likely to carry out household chores compared with boys; girls and women spend more time on unpaid caring roles and domestic work; men and boys are more likely to pursue physically demanding jobs. Despite some attempts to tackle differences in the gender split for school subjects, cultural expectations mean there are still gender based differences which ultimately lead to different career choices in later life.

Children are aware of, and actively engage in gender stereotypes from an early age with most starting to show their gender identity at around two to three years of age.

They may do this by choosing certain toys, colours and clothes that seem to appeal more to girls or boys, decisions which are often reinforced by parents and family members and certainly by the toy, publishing and clothing industries, which potentially limit children's interests by promoting their products by gender. Gender roles and gender norms are proven to disproportionately affect girls.

By challenging gender norms, we can help promote positions of social and political influence for women and girls in our communities and address the power inequities. Every child in Gateshead, regardless of gender, deserves an equal chance to survive and thrive, and that begins during pregnancy and throughout their early years.

To improve life chances for babies and to challenge gender norms across our society, it's important to focus on women's health during pregnancy and enable women to make healthier choices throughout their pregnancies. 

A recent UK study has found that mortality rates have increased and sadly, between 2018 and 2020, 229 women died during or up to six weeks after the end of pregnancy.
(Knight M, Bunch K, Patel R, et al. (2022). Saving lives, improving mothers' care. MBRRACE-UK)

(Knight M, Bunch K, Patel R, et al. (2022). Saving lives, improving mothers' care. MBRRACE-UK)

Healthy pregnancy has positive outcomes for us all and we all have a role to support women in having pregnancies that are as healthy as possible. There are many opportunities to support women to have healthy pregnancies by ensuring that the environment in which they live, work and socialise is healthy and beneficial to them and their babies.

Here, we look at what support is available for pregnant women in the workplace, ways to stop tobacco exposure, reducing the risk of domestic abuse, the importance of breastfeeding and the impact of post-natal depression.

Although there are laws against pregnancy discrimination in the workplace, discrimination still occurs. It's estimated that 54,000 women in England a year feel they must leave their jobs due to pregnancy or maternity discrimination.
(Department for Business, Energy & Industrial Strategy. (2022). Government backs new law to help pregnant women and new parents stay in work)

We know that discrimination has real consequences for a pregnant employee's career, including reduced salary and lack of promotion. It also has health consequences for them and their babies. The most common health risk related to pregnancy discrimination is an increase in mother's stress, which can increase their risk of antenatal depression. This stress can also lead to lower birth weight and increased visits to the local doctor. The longer-term impacts on the mother's health remain where mothers continue to suffer poorer health, depressive symptoms and parental stress.
(Hackney KJ, Daniels SR, Paustian-Underdahl SC et al. (2021). Examining the effects of perceived pregnancy discrimination on mother and baby health. J Appl Psychol. 106(5):774-783)

In the UK, pregnant employees have four main legal rights:
(GOV.UK (2022). Pregnant employees' rights.)

• paid time off for antenatal care
• maternity leave
• maternity pay or maternity allowance
• protection against unfair treatment, discrimination or dismissal

To improve a more positive environment and offer support, businesses can:

1. Help negotiate parental benefits for their employees

A manager's initial reaction shapes perceptions of future and therefore can impact on stress levels. It's key to support employees and to maintain an open dialogue with employees.

2. Offer flexible work options

Managers can help pregnant employees by offering flexible work arrangements, such as remote working and flexitime. To support pretreatment pregnant employees, it's key to normalise that flexible working arrangements are rights, not special privileges. 

3. Accommodating time off for healthcare appointments

Antenatal care requires attending regular and increasingly frequent health care appointments and is not just medical appointments - it can include antenatal, relaxation classes or parenting classes if they've been recommended by a doctor or midwife. Allowing pregnant employees to leave early, arrive late and/or work remotely when they have appointments is critically important for the health of the baby and employee.

4. Facilitating interactions with co-workers

Employees who feel supported by both co-workers and supervisors/managers benefited from the largest reductions in postpartum depression and quicker physical recovery following the birth of their child.

5. Intentionally creating an inclusive organisational culture

Inclusive behaviours signal that all employees are welcomed and valued, no matter their gender, health, parental status or other dimension of difference. This makes it more possible for employees of all identities to thrive. Managers can ask questions about their pregnant employees' experiences at work and actively listen to what pregnant employees have to say.

Gateshead Council has a 'maternity scheme' which applies to all pregnant employees regardless of the number of hours worked per week (it excludes teachers, who are covered by a separate policy). The Council also has an 'adoption scheme' and a 'paternity scheme'.

Within each scheme, it clearly states who and what is covered. For example, in the maternity scheme, pregnant employees have the right to paid time off for antenatal care whereas for the adoption scheme, employees are given up to three days' paid time off to attend pre-adoption training, which helps them understand the adoption process. Paid leave is provided, with the length depending on length of service. 

Keeping in touch (KIT) days are also incorporated in the policies, which is important for both employers and employees as they are intended to facilitate a smooth return to work for all.

It is evident that Gateshead Council, alongside its partners including health, police, and fire and rescue service, strive to have positive environments for pregnant women and their partners, as well as for employees who are adopting. There's opportunity to keep sharing good practice across the sectors.

Protecting pregnant women and babies from tobacco smoke is one of the best things we can do to give our children a healthy start in life.

Approximately one in five (20%) women are exposed to second-hand smoke in their home throughout their pregnancy, leading to many of the same adverse birth outcomes experienced by women who smoke, such as low birth weight and premature births.
(Smokefree Action. (2022). Supporting partners to quit smoking.)

Women who live with a smoker are six times more likely to smoke throughout pregnancy and those who live with a smoker and manage to quit are more likely to start smoking again once the baby is born. As such, we must consider all family members when stopping exposure to tobacco as well as providing support for our mothers.
(Royal College of Paediatrics and Child Health. (2020). Smoking during pregnancy)

Stopping smoking helps both the mother and their baby immediately. And quitting smoking at any stage of pregnancy has health benefits - just one day of not smoking will allow the baby to get more oxygen and help their lungs to develop. 

Even stopping in the last few weeks of pregnancy benefits mothers and their babies. It's also important that mothers have support to remain smokefree once their babies are born.

The percentage of mothers who smoke at the time of delivery is gradually reducing in Gateshead. Local data from Gateshead Health NHS Foundation Trust suggests in the year April 2021 - March 2022, 12.8% of mothers were smokers at the time of delivery.
(Gateshead Health NHS Foundation Trust, Tobacco Dependency Treatment Service. Local data (unpublished).)

However, this is above the national average of 9.1% and is more than double the national target of 6% by end of 2022. (Department of Health. (2017) Towards and Smokefree Generation: A Tobacco control plan for England)

Smoking at the time of delivery by mother's ethnicity was also explored, but these values have not been shared as there may be some risk of identification due to low overall numbers.

In Gateshead, support is offered to stop smoking through our participating GP practices, pharmacies and community providers. All stop smoking advisors attend local stop smoking training and are trained to support pregnant women to quit smoking.

In 2021, Gateshead Council provided Gateshead Health NHS Foundation Trust with additional funding to support development of the Tobacco Dependency Treatment Service (TDTS). Longer term, this service would be funded by NHS Long Term Plan funding but this initial investment has allowed staff to be appointed and the service to launch well ahead of other areas in the region and even nationally Gateshead is a pioneer in the development of their TDTS service.

The TDTS launched in April 2022 and follows the NHS recommended model which is based on a proven model implemented in Canada and Manchester. This supports our commitments to the prevention of smoking and tackling avoidable illness. By 2023/2024 all people admitted to hospital who smoke will be offered NHS funded tobacco treatment services.

For pregnant women, the offer is more intense and is delivered directly by maternity services. It expands on recommendations in NICE guidance (NG92) to drive engagement which includes four weekly face to-face behavioural support and nicotine replacement therapy. Appointments can be in clinic, in the community or at home, so that the needs of the woman are met. Further appointments throughout pregnancy are offered to help women remain smokefree and to prevent relapse. If there have been no responses, the maternity service will continue to reach out to offer support and encouragement.

Whilst pregnancy can be a time of great happiness and joy, it can also be a time when domestic abuse can get worse or even start for the first time. For this reason, all women get asked about domestic abuse during their pregnancy by their midwives and other health professionals.

It's estimated that almost one in three women who suffer abuse, experience abuse for the first time whilst they are pregnant.
(Grier G and Geraghty S (2015). Intimate partner violence and pregnancy: How midwives can listen to silenced women. British Journal of Midwifery. 23(6).) This makes domestic abuse the most common health problem for women during pregnancy. Domestic abuse is a pattern of assault and coercive behaviour, and can be emotional, physical, psychological, financial and/or sexual.

Local figures highlight the fact that pregnancy is a risk factor for domestic abuse. 1 in 56 women aged 15-49 reported domestic abuse last year in Gateshead (2021).

Approximately 1 in 5 women who are referred to the Domestic Abuse Team (aged 15 - 49) are pregnant or have recently given birth. (Gateshead Council. (2022) Local Data (unpublished). ONS. (2022) Population and household estimates, England and Wales: Census 2021, Sex by single year of age. ONS. (2022) Conceptions in England and Wales: 2020)

Domestic abuse brings many risks for both the pregnant woman and their unborn baby, including infection, premature birth, miscarriage, injury or death. Domestic abuse can also affect a woman's mental health and wellbeing as well as aggravate existing health problems or chronic pain conditions.

One of the side effects of domestic violence is stress and anxiety, which can affect the way babies grow and develop, resulting in long term negative outcomes for babies. Women who are being abused may also worry about how competent they will be as a mother and their ability to love and protect their baby. 

It's important to disclose if domestic abuse is taking place, and everyone should be assured that it will be treated in a totally confidential manner. We must all remember that domestic abuse is not the fault of the victim/survivor and we must ensure that people are supported and encouraged to report their experience to someone, whether that's a health professional, the police or a charity.

Here in Gateshead, women are asked about whether they are experiencing domestic abuse as part of a routine inquiry model within the pregnancy pathway. During each appointment, women are asked how they are, how things are at home, how their partner is, if they feel safe at home.

Maternity staff have been trained in this approach and receive regular clinical supervision with the safeguarding lead midwife where they are able to reflect on their practice.

Breastfeeding has major long-term positive effects on the health, nutrition and development of the mother and child's physical and mental health. It's an investment in every child's future. The World Health Organization (WHO) recommends breastfeeding initiation within an hour after birth, exclusive breastfeeding for the first six months of life, followed by the introduction of complementary foods alongside continued breastfeeding until the child is at least two years old.
(World Health Organization. (2023). Breastfeeding.)

Breastfeeding is highly emotive in the UK because so many mothers have either not Breastfed or have experienced trauma from trying to breast feed unsuccessfully. Many mothers and babies find breastfeeding difficult, with the first four to six weeks thought to be the toughest time. As such, we need to support mothers and their partners. For example, women may not feel comfortable to go back to work due to lack of feeding space, or women who cannot afford to take longer maternity leave might feel like they can't breast feed. There are many reasons that impact on a women's decision and ability to breast feed, including both socio-cultural and biological factors. 

According to information from the Gateshead Health NHS Foundation Trust, 69% of women initiated breastfeeding after birth in 2020/21.
(Gateshead Health NHS Foundation Trust. Local data (unpublished).) 41% of women were still breastfeeding 6-8 weeks after birth. 

Although this is lower than the national rate (49%), encouragingly, the percentage has increased over time and Gateshead has the third highest rate in the North East region.
(Office for Health Improvement and Disparities. (2023) Public health profiles.)

It is important that Government, policy makers, communities and families all share responsibility and make sure that everyone has the choice to breast feed. This could include appropriate support, breastfeeding public space and breastfeeding friendly workplaces.

40.7% of women in Gateshead are breastfeeding at 6 - 8 weeks after birth. This is significantly higher than the North East average, but significantly below the England average.
(Office for Health Improvement and Disparities. (2023) Public health profiles. Office for Health Improvement and Disparities. (2023) Public health profiles.)

Rates have increased by almost 5% in Gateshead since 2016/17. (Office for Health Improvement and Disparities.
(2023) Public health profiles.for Health Improvement and Disparities. (2023) Public health profiles.)

To help mothers and babies to start breastfeeding, it's important to discuss the importance and management of breastfeeding with pregnant women and their families. It's also important that staff have sufficient knowledge, competence and skills to support breastfeeding. Maternity and early years services in Gateshead have infant feeding policies in place which are routinely communicated to staff and parents and provide support to initiate and maintain breastfeeding and manage common difficulties.

In Gateshead, we are committed to providing the highest standard of care to support expectant and new mothers and their partners to feed their babies and build strong and loving parent-infant relationships. 

The service recognises the deep importance of early relationships and parent-infant attachment to future health and wellbeing, and the significant contribution that breastfeeding makes to good physical and emotional health outcomes for children and mothers. All pregnant women have the opportunity to discuss feeding and caring for their babies with a health professional. This discussion will include:

1. The value of connecting with their growing baby in utero.
2. The value of skin-to-skin contact for all mothers and babies.
3. The importance of responding to their baby's needs for comfort, closeness and feeding after birth, and the role that keeping their baby close has in supporting this. 
4. Feeding, including the value of breastfeeding for comfort, protection and food, and getting breastfeeding 'off to the best start'.

Growing Healthy Gateshead has received accreditation for Stage 2 of the UNICEF Baby Friendly Initiative (BFI) in September 2021, gaining excellent feedback about the team and their communication skills used in antenatal discussions and beyond. BFI provides a roadmap for services to improve care and through the staged accreditation programme, services are enabled to support all mothers with feeding and help parents build a close and loving relationship with their baby. Supporting the BFI is the maternity service, which has achieved UNICEF Stage 1 accreditation and is now working towards Stage 2.

Growing Healthy Gateshead is now going for Stage 3 of the award and will be assessed against the standards in December 2022. Once passed, the service will receive the prestigious Baby Friendly award, recognising excellence in the care of mothers and babies. There is a team of passionate breastfeeding champions within the service, who offer more specialised support to mothers and their partners who may be struggling with breastfeeding. 

During the Covid-19 pandemic, Growing Healthy Gateshead adapted and offered face to face, telephone and virtual support to women and families including support on infant feeding. Daily proactive telephone calls continue to be offered to breastfeeding mothers during the first weeks after birth and continue to be based on each family's needs and requirements.

Many women feel nervous about breastfeeding whilst out and about, which can impact on their decisions about breastfeeding and may cause them to stay at home and start to feel isolated. Embarrassment and negative public attitudes have been found as the main barriers to breastfeeding in public, even though the right to breastfeed in public spaces is protected by law, and most women have positive experiences surrounding this.

Infant feeding friends' groups have been set up in partnership with the children's centres in Deckham (Elgin Centre), Blaydon and Chowdene. An infant feeding champion is available to offer support around breastfeeding (positioning, blocked ducts, cluster feeds, attachment) and peer support from other mothers.

The Boob Club is a friendly social group which provides a supportive space for breastfeeding women with an aim to create a 'breastfeeding support village' where mothers can meet, chat and make new friends. It is free to attend.

LINKS Growing Healthy Gateshead also offer support through Facebook and a dedicated app

Women who have a history of mental health problems before becoming pregnant are at increased risk of certain mental health conditions during pregnancy and the year after childbirth. Mental health problems, particularly post-traumatic stress disorder (PTSD), are associated with experiencing a traumatic childbirth, stillbirth or the death of a baby. Unfortunately, there were 4 stillbirths in Gateshead in 2021. This is a rate of 2.0 per 1,000 live and still births, which is lower than the North East and England still birth rates of 4.1 per 1,000 live and still births. (ONS (2022). Births in England and Wales: Summary tables: 2021.)

A recent UK study has found the maternal mortality rate has risen even if women who died from Covid-19 are excluded. The clearest impact on maternal mortality rates is caused by an increase in mental health related deaths, principally women who have died by suicide. 
(Knight M, Bunch K, Patel R, et al. (2022). Saving lives, improving mothers' care. MBRRACE-UK)

In the UK between 2018-2020, Women were 3 times more likely to die by suicide during or up to six weeks after the end of pregnancy compared to 2017-19.

The MBRRACE UK study (2022) found persistent inequalities and continued inequitable care for pregnant women. The study concluded that we must stop the recurring structural biases that affect women's care on the basis of their pregnancy.
(Knight M, Bunch K, Patel R, et al. (2022). Saving lives, improving mothers' care. MBRRACE-UK)

Gateshead is in the process of developing its start for life offer (from conception to age 2) for parents and carers who need support for mild to moderate mental health needs, or for those who would benefit from universal parent-infant support with an emphasis on fathers and co-parents.

Breastfeeding support is to be further enhanced as part of the Start for Life offer so that it is available to all parents and carers. 

It's estimated that nationally, 2 in every 1,000 women suffer from post-partum psychosis following pregnancy. Comparing this to the number of births in Gateshead (1,987 live births and still births), this would equate to approximately four women in 2021.
(Office for Health Improvement and Disparities. (2023) Public health profiles.) (ONS (2022). Births in England and Wales: Summary tables: 2021.)

The estimated number of women with severe depressive illness, calculated by applying the national prevalence estimate (30 in 1,000) to the total number of births (1,987) in Gateshead, would equate to around 60 women with severe depressive illness in the perinatal period. This calculation does not account for women whose pregnancies ended in miscarriage.
(Office for Health Improvement and Disparities. (2023) Public health profiles.) (ONS (2022). Births in England and Wales: Summary tables: 2021.)

Family Hubs will provide a single access point - a 'front door' - to universal and early help services for families with children of all ages (0-19) or up to 25 with special educational needs and disabilities (SEND), with a Start for Life offer at their core. Family Hubs involve co-location of services and professionals to make it easier for families to access the services they need, including Start for Life services, and this can include both physical locations, outreach support and virtual offers. 

Family Hubs are a way of delivering the Supporting Families Programme vision of an effective early help system, providing place-based access to SEND services, 0-5 activities, youth services, advice on debt and housing, support for mental health, smoking cessation, nutrition and weight management, help for those experiencing domestic abuse and relationship conflict, plus funded strands of enhanced support for: 

• Parenting support 
• Perinatal mental health and parent-infant relationship support 
• Early language development and home learning environment
• Infant feeding support

This service is being developed and will be fully in place by the end of March 2025.

Debbie Corbett started her career as a midwife eight years ago and is now the Public Health Lead Midwife at the Queen Elizabeth Hospital. The team also consists of specialist midwives for tobacco dependency, infant feeding, screening, safeguarding and preterm birth.

Debbie tells us the following key areas are just some of the priorities for her and her team: 

• Tobacco dependency in pregnancy
• Healthy weight in pregnancy
• Pregnancy vaccinations
• Perinatal mental health
• Infant feeding
• Safe pregnancy spacing and postnatal contraception
• Alcohol in pregnancy
• Making Every Contact Count (MECC)
• Learning disabilities

Working together, the maternity team at the Queen Elizabeth strive 'to improve the health and wellbeing of Gateshead mothers and their families, giving babies the best start in life is key to reducing health inequalities.' Acknowledging that 'maternity care has the opportunity to promote positive lifestyle change and by working collaboratively with other services, Maternity Voice Partnerships and stakeholders we can improve services, safety and outcomes for women and their families.' 

Debbie states, an important and key feature in her role as a Public Health Specialist Midwife is to 'ensure that the core public health agenda is safely and effectively embedded in our operational procedures and work streams to provide safe service and reduce health inequalities for our mothers, babies and their families.'

I am responsible for Gateshead Children's Centres and Play Service teams. Gateshead's Children's Centres provide activities and services for children under 5 years and their parents/carers. This includes activities designed to support the child's development and prepare them to start nursery. Our Children's Centres and linked sites also give help and advice on child and family health, parenting, money, training, and employment.

Gateshead's Play Service provide play activities for children and young people aged 5-17 years. Play activities offer valuable respite for families and social opportunities, physical activity, sensory play, and lots of fun for children and young people.

Our Parent Outreach Workers report that women in Gateshead may be vulnerable due to lack of social support, language barriers or mental health problems. Young mothers can face social stigma which can make parenting stressful.

To tackle this, we work with our social care, health, and education partners to identify vulnerable and disadvantaged mothers and offer them support to access our activities and services. This may include reaching out and attempting to build a relationship before their first visit. Parent Outreach Workers then try to reduce some of the barriers to accessing our services such as travel, cost, and confidence.

Our Children's Centre team is relatively small, so we rely on partnerships to provide the activities and services required. Our partnerships help bring services to Children's Centres including mums talk with talking therapies, Citizens Advice drop in and football for women and girls. It is vital that we continue to build on these partnerships and support our partners to deliver their services through the development of our Family Hubs approach.

I'm Sophie, a single mother of a baby boy, under the age of one. We live in supported housing, and I need to be self-sufficient, so I am good at managing money. I am very cautious and before I had my baby, I did not have much self-confidence. The Family Nurse Programme was offered to me early in my pregnancy when I was not in the best place, but with the help of my nurse I was quickly able to find some stability and really think about my unborn baby. I'd always wanted to be a mother so now I could start to live out one of my dreams.

My baby was - and still is - my priority, I'd already had to make some big decisions about where I lived and who I saw but now I wanted to make sure I gave my baby the best start. My nurse set up a session on infant feeding, but I had already started to think about breastfeeding. I'd talked to some of the young mothers at a local group I was attending, and they'd said that they had tried to breast feed but given up and then later wished that they had kept going. I discovered why all the health professionals were promoting breastfeeding and I liked the idea of giving my baby a boost to his immune system. I remember my nurse saying that if my baby catches a bug then I am likely to catch it too as we would be very close and that I could make antibodies to the bug and then give these to my baby through my breast milk; this sounded amazing, being able to help protect him from illness. With my money head on I also liked the idea that it was free!

I had an amazing birth and the midwives helped me to initiate breastfeeding. My baby was - and is - beautiful and latched well but it was not plain sailing. I did become a little sore and my nurse helped with nipple cream but what made a massive difference was a breast pump which she hired for me from our local Children's Centre. Not only was I able to express and rest my nipple but, not feeling confident feeding in public, I eventually managed to express enough to give my milk via a bottle. I feel much more confident now and there are ways I have learnt to feed discretely.

I was asked what kept me going through the difficult uncomfortable times, and there were some of those. I only had to look at how the closeness of feeding was helping to soothe and comfort my baby, how he settled well to sleep and how content he was. I did not have anyone who I could ask to come and take over and help in these moments, especially at night and this worked. Yes, I was sore, but I was of the mindset that I was not going to stop, I kept the thought of my friends in my head who said they regretted stopping and I was determined to keep going.

My nurse visited and encouraged me and weighed my baby regularly. It was a relief to see that he was gaining weight steadily, this was further motivation and it was always good to know that my nurse was available on the other end of a text message when needed.

When I look at my baby boy I feel incredibly proud, we are so close, I feel I know him so well and understand even the smallest of his cues. I feel that breastfeeding has brought us together and helped me believe in myself that I can do things that are often challenging and succeed. It is so convenient, ready to go and always at the right temperature, I do believe that I have saved time as well as money! We've started weaning now onto solid foods but he still enjoys the comfort of feeds and I too treasure our time together feeding and our unique bond.

When asked what I would say to other young mothers-to-be rather making decisions about feeding their baby, I would say 'give it a go, you have nothing to lose. Do not feel pressured but you just might enjoy it as I am doing, one of the best decisions I have made'

Chapter 2: Enable children, girls and women to live their lives to their fullest